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Exploring Methodological Issues in Mental Health

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Exploring Methodological Issues in Mental Health FACULTY OF HEALTH S C I E N C E S SOUTHERN DANISH UNIVERSITY PSYCHIATRIC RESEARCH UNIT REGION ZEALAND PhD thesis Lene Halling Hastrup Exploring methodological issues in mental health economic evaluations: illustrated in relation to community mental intervention among persons with first-episode psychosis PhD thesis Exploring methodological issues in mental health economic evaluations: illustrated in relation to community mental health intervention among persons with first-episode psychosis Lene Halling Hastrup 3 Author Lene Halling Hastrup, MSc (Economics) Psychiatric Research Unit, Region Zealand Supervisors Dorte Gyrd-Hansen, Professor, PhD, Institute of Public Health, Southern Danish University & Australian Centre for Health Economic Research on Health, University of Queensland, Merete Nordentoft, Professor, MD, DMSc, Psychiatric Center Copenhagen, Mental Health Services in the Capital Region of Denmark and Faculty of Health Sciences, University of Copenhagen Christian Kronborg, Associate Professor, MSc., PhD, Institute of Public Health, Southern Danish University & Erik Simonsen, Professor, MD, PhD, Dr.h.c., Psychiatric Research Unit, Region Zealand and Faculty of Health Sciences, University of Copenhagen Review committee Chairperson: Professor Jan Sørensen, Southern Danish University Professor Carl Hampus Lyttkens, Lunds Universitet Associate Professor Ulrika Enemark, University of Aarhus Submitted November 2, 2011 Public defense June 1, 2012 4 Foreword This thesis is the result of three years of work at Psychiatric Research Unit, Region Zealand. I was enrolled two years at the University of Copenhagen and the final year at the Institute of Public Health at University of Southern Denmark. Region Zealand financed the Ph.D. project. The idea to the project came up when I was working as Project manager at Storstrøms County evaluating an Assertive Community Treatment (ACT) project, which was carried out at Falster and Southern Zealand. For me as an economist, the psychiatry was a new and interesting field, and I realized during my employment that there was an increasing interest from researchers and decision makers for health economic research of mental health interventions. I am indebted to many people who have helped me in various ways. First of all, I am indebted to my supervisors. I would like to thank my main supervisor Dorte Gyrd-Hansen for being optimistic and at the same time realistic about the project all the way through and for continuously helping and inspiring me with her pragmatic way of thinking. Even though, Dorte has lived in Australia for most of the time, I have never felt that her help and support was far away. I would like to thank Merete Nordentoft, who was the first to introduce me to schizophrenia and other severe mental illnesses and community mental health interventions. Merete has also inspired and encouraged me to do this thesis, and she has been interested in and supported my work with mental health economics all the way through. I would like to thank Christian Kronborg, who introduced me to using STATA and showed me how to analyze large amounts of data extracted from various Danish registers. He also helped me to conduct the economic evaluation of OPUS. I would like to thank Erik Simonsen for his support and interest in my thesis, and especially for his care during the final process. I would like to thank Per Vendsborg, Birgitte Andersen and Søren Blinkenberg for believing in the idea of the project. They have all helped and supported me in realizing the Ph.D project in Region Zealand. I would also thank the Falster OP-team who shared their knowledge and valuable experiences about ACT and patients with severe mental illnesses with me. 5 I would like to thank Region Zealand for funding my Ph.D. and 'Region Sjællands Sundhedsvidenskabelige Forskningsfond' for financial support to register data via remote access to Danish Statistics. I would like to thank Marianne Espenhain Nielsen, Kirsten Buch Rasmussen and Trine Lacoppidan Kæstel for helping and advising me in doing the literature search. I would also like to thank all of my former and current colleagues at the Psychiatric Research Unit in Vordingborg and Roskilde for their interest, support and for sharing their knowledge with me, and Dorit Mortensen for helping me with arrangement of the PhD defence and preparing the thesis before printing. Finally, I would like to thank my family for their care and support. A special thank is to my parents, Helen and Poul, for their hospitality during the last months of the writing process. Most of all, I want to thank my husband, Michael, for his love, for believing in me, and for helping me and putting up with me when I was absentminded. I thank our three children, Elisabeth, Albert and Lili, for being with me. Lene Halling Hastrup May 2012 6 TABLE OF CONTENTS Foreword...…………………………………………………………………………………...….5 Table of contents…...……………………………………………………………………………7 Executive summary…...………………………………………………………………………....9 List of articles….………………………………………………………………………………11 Outline of the thesis………..………………………………………………………………..…12 1 Introduction……………..…………………………………………………………………....15 1.1 Schizophrenia………..…………………………………………………………………......15 1.2 Community based treatment of mental health ……….…………………………………....16 1.3 Clinical evidence of Assertive Community Treatment …..………………………………..17 1.4 Clinical evidence of early intervention treatment in first-episode psychosis…...………....18 1.5 Health economic evidence of early intervention in first-episode psychosis...……..………20 1.6 Summary………………………………………………………………..……………….…24 2 The theoretical framework……………………………………………..…………………….25 2.1 Welfare economic foundation……………………………………..……………………….25 2.2 Health economic evaluation…………………………………..…………………………....27 2.3 Assessment of costs………………………………………………….…………………….31 2.4 Measuring and valuing informal caregiving…………………….……………………..…..33 2.5 Choice of outcome…………………………………………….………………………..….36 2.7 Summary…………………………………………………….………………………….….38 3 Research questions………………………………………….…………………………….….41 4 Is early intervention in first-episode psychosis cost-effective? (Article 1)……………….…43 5 Are resources distributed to those individual mostly in need? (Article 2)……………….….71 6 Do informal caregivers in mental health feel more burdened? (Article 3)……………….….85 7 Does the EQ-5D measure quality of life in schizophrenia? (Article 4)……………………...96 8 Summary and concluding remarks………………………………………………………….119 Danish summary……………………………………………………………………………...125 References………………………………………………………………..…………………...129 7 8 Executive summary The thesis aims to contribute to mental health economics by answering four methodological and policy relevant questions. The research questions constitute important areas of research relating to economics of community mental health care, with focus on current lack of economic evidence and methodological issues identified in Chapter 1 and 2. Four research questions were addressed in the thesis by way of four original research journal articles (Article 1 to 4). 1) Is early intervention in first-episode psychosis cost-effective? Since the current economic evidence of early intervention in first-episode psychosis is ambiguous, this study aimed to conduct an economic evaluation of the largest RCT study to date. Adopting a comprehensive public sector perspective, the economic evaluation of the OPUS study found the two-year specialized early intervention program (OPUS) could be implemented at the same costs as treatment as usual, but with better outcome. It is concluded that a longer observation period (5 years) will affect cost effectiveness outcomes. 2) Are mental health care resources distributed to those individuals mostly in need? Mentally ill patients can have difficulties in engaging with services and are at a greater risk of being lost to the system. The association between individual baseline characteristics of newly diagnosed first-episode psychosis patients and their future consumption of health care services was assessed. It was found that personal characteristics, which indicate severe illness (higher symptom level, lower functional level, having a substance abuse, and being homeless) was statistically significantly associated with higher future costs. The findings suggest that within this specific Danish community mental health setting, resources are distributed according to need. 3) Do caregivers of patients with mental illness experience a higher subjective caregiver burden than other caregivers? Current evidence suggests that caregivers to patients with mental illnesses suffer from a substantial burden. In a sample of 865 Dutch informal caregivers it was found that being informal caregiver to a care recipient with a mental illness was associated with an added subjective and objective caregiver burden measured by the Caregiver Strain Index (CSI). A higher caregiver burden was experienced by carers who are a child or partner of care recipient, 9 have a paid job, have a low health-related quality of life or suffer from illness. It is concluded that including the cost of caregiving is highly relevant in the context of mental health. 4) Is it appropriate to apply a generic preference based quality of life measure (EQ-5D) in the context of mental health? Current evidence suggests that using existing preference-based generic quality of life instruments may be problematic in mental health populations. Using baseline data of 103 patients with schizophrenia spectrum disorders and cannabis abuse, it was assessed how quality of life aspects as
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